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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: TR{'cCX MU N I G PPrL NFPOQT <br /> FACILITY ADDRESS: <br /> TANK M #39 - Tank Description: <br /> SECTION 2 - To be filled out by tank removal contractor: � <br /> Tank Removal Contractor:��( (V�f . �N nmy)v1hP�YT�K- � <br /> Address:�n 1OR S( ?=L, City: p: <br /> Phone #: t 3l0 �a2 ��� Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: { ICJ'-SOIL I�L - <br /> Address: '-Lt5j Pf"RR SL , city: KACHMO-KD zip: q4l;o <br /> Phone #: (5j�0 ) 23C; — k--'2A 3 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: �GKSDN Ihr <br /> Address: a5S P/d 2M $L . city: zip: <br /> Phone #: <br /> Date Tank Received: <br /> Signature: Title: <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />